Credentialing Specialist

Description

 Evaluate, analyze, and coordinate all aspects of the credentialing and re-credentialing processes for practitioners practicing within the CAIPA Network. Provides integral support to healthcare operations by enabling timely onboarding of healthcare providers. 

Duties and Responsibilities 

1. Reviews and screens initial credentialing and re-credentialing applications for completeness, accuracy, and compliance with federal, state, local and Managed Care regulations, guidelines, policies, and standards. 
2. Conduct primary source verification. Collects and validates documents to ensure accuracy of all credentialing elements; assesses completeness of information and qualifications relative to credentialing standards. 
3. Identifies, analyzes, and resolves extraordinary information, discrepancies, time gaps, and other idiosyncrasies that could adversely impact the ability to credential and enroll practitioners; discovers and conveys problems to the Credentialing Manager for sound decision-making per CAIPA's credentialing policies and procedures, federal, state, local and government/insurance agency regulations. 
4. Monitors files to ensure completeness and accuracy; reviews all file documentation for compliance with quality standards, accreditation requirements, and all other relevant policies; prepares and provides information to internal and external customers as appropriate. 
5. Enters, updates and maintains data from provider applications into credentialing database, focusing on accuracy and interpreting or adapting data to conform to defined data field uses, and in accordance with internal policies and procedures. 
6. Prepares, issues, electronically tracks, and follows up on appropriate verifications for efficient, high-volume processing of individual applications in accordance with applicable credentialing standards, established procedural guidelines, and strict timelines. 
7. Participates in the development and implementation of process improvements for the system-wide credentialing process; prepares reports and scoring required by regulatory and accrediting agencies, policies, and standards. 
8. Communicate clearly with providers and their liaisons, leadership, Credentialing Committee Members, insurance payers, and others as needed to provide timely responses upon request on day-to-day credentialing issues as they arise. 
9. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of the latest developments to enhance understanding of various regulations and legislation of the health care industry. 
10. Performs miscellaneous job-related duties as assigned. 

Requirements

• High school diploma or GED 

Knowledge, Skills, and Abilities Required 

• Ability to communicate effectively both orally and in writing. 
• Customer service skills. 
• Ability to respond to emails timely and effectively. 
• Information research skills. 
• Ability to use independent judgment and to manage and impart confidential information. 
• Ability to maintain confidentiality and discretion in all communications on behalf of credentialing applicants and/or applications. 
• Ability to make administrative/procedural decisions and judgments. 
• Demonstrated working knowledge of Microsoft Word and Excel. 
• Ability to learn new applications to function effectively in a remote work environment. 
• Skill in establishing priorities with independent coordination of day-to-day aspects. 
• Advanced skills in computerized spreadsheets and database management preferred.  
• Knowledge of medical provider credentialing and accreditation principles, policies, processes, procedures, and documentation preferred.  
• Working knowledge of clinical operations and procedures preferred.